In Network Rate File | Allowed Amount File | |
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GENERAL REQUIREMENTSa complete overview at Subpart B-Public Disclosure Requirements): |
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STANDARD CHARGESThe following data points (columns) are required for each charge item: | Negotiated rate – the amount a group health plan or health insurance issuer has contractually agreed to pay the in-network provider, including an in network pharmacy or other prescription drug dispenser Derived amount (if applicable) – relevant when the negotiated rate is something other than fee-for service, such as a bundled payment Underlying fee schedule rate (if applicable) – likely to be relevant when the negotiated rate corresponds with an alternative payment model, such as a capitation. The rate for a covered item or service from a particular in-network provider…that a group health plan or health insurance issuer uses to determine a participant’s or beneficiary’s cost-sharing liability for the item or service, when the rate is different from the negotiated rate or derived amount | Billed Charges – defined as the total charges for an item or service billed to a group health plan or health insurance issuer by a provider Out of network allowed amounts – defined as the maximum amount a group health plan or health insurance issuer will pay for a covered item or service furnished by an out of network provider |
Format |
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Naming Convention |
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Location of information | Displayed prominently on a publicly available website and in a prominent manner that clearly identifies the health plan’s location with which the information is associated | |
Access to information | No barriers to access: Free of charge, no account or password required; No Protected Health Information required to access No submission of any Personal Identifying Information | |
Updates | Monthly – with date of last update clearly indicated FOR ADDITIONAL DETAILS ON THIS REQUIREMENTS REFER TO: | |
Future Requirements |
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Please note, beginning July 1, 2022, CMS will monitor and enforce these price transparency requirements. For health plans that do not comply:
- They may be issued a warning notice by CMS
- After receiving a warning notice, CMS will request a corrective action plan
- CMS may impose a civil monetary penalty up to $100 per day adjusted annually under 45 CFR part 102. For additional details on enforcement refer to 45 CFR part 150.
Resources: